Provider Demographics
NPI:1902302680
Name:TALL BULL, KODI DANIELLE
Entity Type:Individual
Prefix:
First Name:KODI
Middle Name:DANIELLE
Last Name:TALL BULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2827 FORT MISSOULA RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7408
Mailing Address - Country:US
Mailing Address - Phone:406-327-3805
Mailing Address - Fax:406-327-4480
Practice Address - Street 1:2230 N RESERVE ST STE 402
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1364
Practice Address - Country:US
Practice Address - Phone:406-721-0533
Practice Address - Fax:406-728-4463
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-129860363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily